Kiwiblog

Martin Johnston at NZ Herald reports:

Some Auckland surgeons are being paid more than $6000 for a day’s work at a public hospital.

My God. They are part of the 1% scum.

The Waitemata District Health Board scheme has divided doctors over concerns that the surgeons involved can earn nearly four times as much as general physicians and psychiatrists on their collective agreement’s top step.

Income inequality alert. This is evil and must be stopped.

The Waitakere “pilot” project pays orthopaedic surgeons a contract rate of $2200 for each total hip or knee replacement package of care. This comprises $1320 for the operation plus $880 for daily patient review, any call-backs during the hospital stay, availability for six weeks after surgery and a six-week visit.

A fixed cost per operation. We can’t have that.

On the union-negotiated multi-employer collective agreement, specialists of all kinds on the highest step earn an annual base salary of $206,000, or $99 an hour, but this increases to around $170 an hour when leave, KiwiSaver and allowances are factored in. Some specialists are paid above the collective’s rates.

Good God, they get paid even more than stevedores.

Senior doctors’ union executive director Ian Powell said the split rates undermined the team-work that was critical to the safety of patients in a complex public hospital.

Oh yes, because one doctor is paid more than another, they will compromise patient safety. I have to say I don’t know any doctors like that.

So why is the DHB doing this nasty income inequality with its doctors?

DHB chairman Lester Levy said the pilot had worked very well.

The rates paid to orthopaedic surgeons were around 60 per cent of private-sector rates. The scheme had led to a number of surgeons opting to do less private-sector work in favour of doing most of their work on public patients.

Productivity was up by a third. Costs shrank 12 per cent for hips and 16 per cent for knees because of a 40 per cent reduction in patients’ average length of stay in hospital, less time in theatre and fewer staff being involved in treatment.

Bringing previously out-sourced surgery in-house saved the DHB $3 million in the last financial year. Patient satisfaction was high and the transfer rate to North Shore Hospital was low.

So paying some staff more has saved the DHB money, improved productivity, reduced lengths of stays in hospitals, increased patient satisfaction and reduced the transfer rate.

But despite this, the union is against this because not all staff are paid more, only some.

Labour should be welcoming what Lester Levy is doing. Rather than contract their operations out to the private sector, the Waitemata DHB is now doing them in-house.

The Wairarapa Times-Age reports:

Wairarapa residents have the second best access to elective surgeries in the country.

Health Minister Tony Ryall said more than $11 million had been poured into health service improvements in the region over the past three years and in that time 264 extra elective surgeries have been completed,

One would think this is a good thing, right?

Mr Ryall said performance efficiencies in Wairarapa over the past three years included more specialist appointments and shorter waiting times in emergency departments and for cancer radiation treatment.

There had been a 25 per cent increase in publicly funded chemotherapy clinics, record levels of immunisation, and improved diabetes and cardiovascular services and help for smokers to quit, he said.

Also sounds good I would have thought?

However, Wairarapa Labour candidate Michael Bott said the increases in elective surgery turnover “may not be all they seem” and that other health services in the region had been sacrificed for increased surgical funding. …

“The fact is that funding cuts have reduced the capacity of many health services. Front-line staff are doing back office work as well and everything else is getting squeezed to put more money into sexy elective surgery numbers,” Mr Bott said.

So Bott thinks elective surgery operations are “sexy’. In the dismissive context he uses it, he implies superficially attractive but not really that important.

I wonder if Mr Bott has ever been in need of surgery, and had to wait years on a waiting list? I suspect he would be less dismissive of it then.

Kathryn Powley in the HoS compares:

The Nats are promising to cut elective surgery waiting times from six to four months and boost the number of operations by 4000 and increase med school places.

Labour would develop “nationwide tools for elective surgery prioritisation based around timelines, equity and quality”. Hmm, concrete promises with dates, times and numbers attached, or long-term strategies, principles and vision? What’ll it be, voters?

I think this sums up the difference wonderfully. Ryall has focused on measurable important improvements, while Labour just have meaningless waffle.

The last Labour Government had dozens of strategies for the health sector. I think there was something like 50+ different goals and targets. The result was massive waiting times for operations, cancer patients flying to Australia for treatment, and huge queues in A&E.

Yesterday Labour launched their health policy. I don’t think I have ever come across such a waffly policy full of principles, reviews, develop systems, strengthen, align. It’s 28 pages of waffle. Almost the only specific is, well I let John Pagani reveal it:

National has flatly rejected Labour’s proposals to once again ban junk food in schools.

John comments:

That sort of policy is asking for trouble.

So good old nanny state Labour are back to their worst. No pie is safe. The food police return.

And what has Labour been up to today:

Labour’s thinly-veiled attacks on Prime Minister John Key have continued today with leader Phil Goff bringing up the subject of Hawaiian holidays.  …

“People at the top have got a lot of money and they take their holidays in Hawaii,” Goff said.

The politics of hate and envy. Because John Key has not spent the last 30 years as an MP, and actually went into business, he is one of those despicable rich pricks.

It is sad to see Phil Goff succumb to Key Derangement Syndrome. Goff generally is a decent man, but he is trashing his own reputation as he continues down this line.

Meanwhile what has National announced today? Also a health policy, on waiting times:

Ensure all patients booked for elective surgery receive it within no more than four months by the end of 2014.

Compare that to Labour’s waffle. A specific commitment, that matters to New Zealanders.

And National has a good record here. Since 2008:

• 60,000 more patients got elective surgery than the previous three years
• An extra 27,000 patients a year getting elective surgery – an increase of 22% since 2008
• 91% of patients getting elective surgery within 6 months of being on the waiting list

So Labour is focused on banning pies and where John Key’s family choose to holiday, and National is announcing it will boost elective surgery by a further 4,000 operations a year and cut waiting times by a further two months.

It shows who is focused on the issues that really matter to New Zealanders. It shows why hopefully Labour is dropping in the polls and hopefully will be crushed on November 26.

Tony Ryall announced:

A record 145,414 patients received elective surgery in the year ended July 2011 says Health Minister Tony Ryall.

Elective surgery operations include hip and other joint operations, cataracts and grommets amongst other important life improving surgeries.

“This means an extraordinary extra 27,000 patients a year are now benefiting from elective surgery compared with the numbers treated under the previous Government”, Mr Ryall says.

“Over the term of this Government, around 60,000 more elective operations have been delivered over the three years.

This would be a good achievement if it occurred during a time when the Government had massive surpluses and could throw unlimited dollars into Vote Health.

To manage to get an extra 27,000 elective operations a year during a time of our largest ever fiscal deficit, and a global recession is quite extraordinary.

Grant Robertson blogs at Red Alert:

The conventional wisdom is that Tony Ryall is making a good fist of the Health portfolio. Now that I am up close in the area I can say that he keeps a tight rein on matters health, and is managing the portfolio effectively.

I’m trying to recall the last time an Opposition Spokesperson said the Minister is managing the portfolio effectively. Good on Grant though for acknowledging the reality. Of course he has a criticism:

But there is a big difference between managing the politics of health and actually doing what is right for the long term health outcomes of New Zealanders.

So what does Grant mean by this:

The best evidence of that is the release today of the Child Health Monitor Report. It shows, among other things, that in the last two years there have been an additional 5 000 avoidable hospital admissions for things like respiratory illness and skin infections. The authors of the report note that the cost of going to the doctor, especially after hours is a factor in whether children are getting the healthcare they need, along with a range factors associated with child poverty.

I am not saying all of this is down to the Health policy of the current government. But the focus on the narrow range of health targets set by the Minister means that child health is not the priority it should be. The Minister has narrowed the health targets in such a way as to scratch the itches of waiting lists and time spent in ED, but it is at the expense of early intervention and public health programmes.

So what are these itches that Grant refers to? An itch suggests something that isn’t that important, but is noticeable. Well the six targets are:

1. Shorter Stays in Emergency Departments
2. Improved Access to Elective Surgery
3. Shorter Waits for Cancer Treatment Radiotherapy
4. Increased Immunisation
5. Better Help for Smokers to Quit
6. Better Diabetes and Cardiovascular Services

Now it might just be me, but I doubt many people would regard shorter waiting times for cancer treatment as just scratching an itch, or having more people get elective surgey or having shorter waits in ED Departments.

These figures were released from Keneperu Hospital under the OIA. The left hand axis is surgical procedures which have grown a staggering 57% in just two years. The right hand axis is outpatient consultations, which have increased 30% in two years.

I think most will agree a far better trend than from 2005 to 2008.

The Dom Post reported:

Poorer New Zealanders are ending up in hospital because they cannot afford to pay for medicines prescribed to them, a study has found.

Maori and Pacific people are especially hard-hit and the study’s author says the only way to ensure equality is for the Government to lower co-payments – the amount patients have to pay for each prescription.

I’m not so sure. We’ll look at details in a minute, but first I’ll make the general point that even when certain health services are free, such as immunisations, they are not fully taken up.

The research, published in the international Journal of Epidemiology and Community Health, found more than six per cent of the 18,000 people surveyed had put off filling a prescription for financial reasons at least once a year.

So 94% do manage to pay the $3 charge. To me that suggests that rather than scrap the fee for everyone, you look at targeting assistance to those on the lowest incomes or greatest health needs.

Who should someone like me not pay the $3?

The other query I have, is were those 6% facing purely the $3 charge, or was there an additional part-charge for some of them as the medicine was not fully subsidised?

That figure jumped to 15 per cent for Pacific people and 14 per cent for Maori.

The results were alarming, lead researcher Santosh Jatrana said.

“We were not expecting that much difference between ethnicities.”

Maori and Pacific people not only tended to be more deprived but were also more likely to have greater health needs, Dr Jatrana said.

But they also have the lowest immunisation rates, and they are free. There may be cultural factors at play, beyond price.

It was worrying that people who had two or more illnesses – and often needed multiple prescriptions – were also avoiding picking up prescriptions, she said.

“Deferral of necessary drugs is only going to make their conditions worse.

“People who put off buying prescription drugs because of cost are more likely to be admitted to hospital with serious acute conditions as they haven’t purchased medication or gone to their GP.”

Overseas studies had shown that people who could not afford all their medication resorted to giving themselves half-doses, skipping doses or spending less on basic needs such as electricity or food.

There was a clear message from the study, Dr Jatrana said. “We need to reduce the co-payments. It’s very simple and straightforward.”

Not at all. Someone has to pay for all these drugs. If 94% of people are paying without problem, why would you stop charging them?

Target the people most in need I say.

The Herald looks for details around the foreshore law:

Unease has been generated by Attorney-General Chris Finlayson’s statement that customary title is “an ownership title”.

This creates a considerable breach with the existing 2004 legislation, which vested the foreshore and seabed in the Crown.

Iwi and hapu whose claims succeed will receive a deed giving title to a coastal area.

They will not be able to sell the property or block public access, but they will have considerable control, including the ability to veto or initiate development, permit activities, and exploit non-nationalised minerals.

He says the compromise reached between the Government, the Maori Party and the Iwi Leadership Group means that, from the staging post of the public domain, there will be few awards of customary title by the courts or as a result of negotiation with the Crown.

That, says John Key, is because the threshold for the granting of such title is high.

Iwi and hapu applicants will have to show continuous and exclusive occupation of the area claimed since 1840.

A test the Court of Appeal said would be hard to meet.

The Dom Post focuses on health issues:

Decisions on health spending are among the most difficult of all those that governments face. They can literally be a matter of life and death.

There are no easy options. Though the public purse is not bottomless, the demand for health services is. There is always a new drug that can be bought or an extra treatment that can be added, always a demand for extra dollars to be spent.

In health, the issue is always where the line is to be drawn, the line that divides patients between those who get to have the state pick up the bill and those who are told that their health needs are their fiscal responsibility.

The line being debated at the moment is who should get bariatric surgery and who should not. The operation costs between $17,000 and $35,000, but has been shown to have dramatic effects on the morbidly obese, with patients halving their weight and with weight-related health problems vanishing along with the kilos.

There are those who will say that the obese have brought it on themselves, and because of that should not be a priority for health spending.

That is not an approach that is applied elsewhere in the health system. Smokers are not told their lung cancer will not be treated because they knew the risks and continued to smoke anyway. Those who spent their summers acquiring a deep mahogany tan are not told that the skin cancer that resulted will be left untreated. And drunk drivers and the thousands of others who injure themselves because they drank too much are not turned away from the hospital doors because they made the wrong choices.

But maybe they should be, to some degree. If you protect people from the consequences of their choices, then they may continue to make bad choices.

If a smoker is told their health insurance premiums will be an extra $1,500 a year because they smoke, that could result in many quitting.

The Press drills into the oil spill:

For BP, the scale of the disaster is such that it looks as though it will bring about the end of the company in its present form. Some estimates suggest that the rapidly mounting costs for the company from the fines and damages it will have to pay could reach $40 billion. Even for a company with annual sales of a quarter of a trillion dollars and profits last year of $17 billion, that is a huge sum to absorb. Already BP has lost half of its value on the sharemarket (incidentally hitting pension funds hard) and it is possible it will have to file for bankruptcy protection and reorganise itself in order to survive. Yesterday it cancelled its dividend (further hitting pensioners and others who are invested in it) in order to pay for a $20 billion fund to meet its present estimated liabilities. The costs are clearly going to spread far beyond the Gulf of Mexico.

The environmental scope of the disaster will not be known for some time. But if the Exxon Valdez could be described as the worst oil-spill disaster in the world, then this one is catastrophically larger. Exxon Valdez was in a remote, sparsely populated part of the world and while wildlife was devastated, the human impact was small. The Gulf of Mexico is just as rich in wildlife and is also, of course, heavily populated. Those people are now seeing their livelihoods, resorts and living areas destroyed.

They have been infuriated by what they saw as a somewhat insouciant response to the calamity by President Barack Obama. It was not helped by a speech he made on Wednesday, which although it gave a pledge that BP would be made to pay for all the damage it was responsible for, also told Americans a truth they have been unwilling to hear – that part of the problem is their addiction to oil-based fuels.

But the president is correct and his remarks apply as much to New Zealanders and others as they do to Americans. Consumers’ continuing addiction to oil have driven prospecting companies to take ever greater risks to meet that continuing demand. The demand itself remains high because those risks are not factored into the price they pay for petrol and other oil products. The Gulf of Mexico disaster emphatically shows that that cannot continue. Markets are already adjusting to this new reality. Consumers will have to do so too.

As oil becomes more expensive, other technologies will become more viable.

The Dom Post reports:

About 250 Wellington patients will have their operations in private hospitals after district health boards decided they could not meet Health Ministry elective surgery targets without help.

Hutt District Health Board is negotiating with Boulcott Hospital to perform about 50 mostly ear, nose and throat operations, while Capital & Coast District Health Board has asked private hospitals to carry out 200 cataract operations.

Hutt chief executive Michael Hundleby said the board turned to Boulcott Hospital because it was concerned that Wellington Hospital – which does 40 per cent of Hutt DHB’s surgery – did not have the capacity to complete the operations.

Some on the left will cry out that this is privatisation. I suppose they would rather those patients simply remain on the waiting list rather than have the private sector provide the operation. Who cares about quality of life so long as we are ideologically pure eh.

Health Minister Tony Ryall said he was not concerned that DHBs were using the private sector to help them meet the health targets, which were introduced last year.

“Our priority is that patients are treated and in the Wellington region we’ve had a record total of 11,232 patients getting the elective surgery they need.”

Great.

The NZ Herald has a story with this headline and opening paragraph:

Lack of Govt cash kills family-health

One of the groups planning an overhaul of primary healthcare services has given up on creating “integrated family heath centres” because the Government is offering no money to help set them up.

So both the headline and the opening paragraph entirely blame the lack of money from the Government.

But for those who actually wade through the story, you find this nugget:

This bid, by the Greater Auckland Integrated Health Network, initially proposed creating up to 12 integrated family health centres. But in its formal business case to the ministry, the network has now quit that concept in favour of a simpler structure involving three “community health hubs”, after GPs rejected the earlier model.

So it was GPs who rejected the earlier model. Are they blaming it on Government cash:

The network’s spokeswoman, Professor Cindy Farquhar, said, when asked if GPs were concerned by the absence of Government funding for integrated family health centres, “Yes, that was a bit of a challenge. In this proposal there is no new money.”

So the media actually put forward the proposition that it is all about lack of money, and the GP spokesperson merely said “Yes, that was a bit of a challenge”.

General practices are mainly private businesses and the Government has no power to force them to create new types of clinics. It has put up $6 million this financial year, but only to manage the change, not to finance new or altered facilities.

So there is funding for transition costs.

Professor Farquhar said the Auckland network rejected integrated family health centres because they would duplicate existing services.

And finally we get the real reason they GPs voted to go with a modified approach.

Now I am not saying that money is not a factor at all, but the headline and opening paragraph (which is all many people read) give a quite false impression of what led to the decision.

The Herald reports:

The Government has delivered a record increase in the number of people who received elective surgery.

Last year, 134,763 patients got elective surgery funded by district health boards, which is in excess of 12,000 more than the number treated in 2008.

That’s a 10% increase, which is a hell of a lot.

The performance far exceeds National’s goal, which was an increase of 4000 a year.

Some of the biggest increases were at Waikato DHB (17 per cent), and in the Auckland region, where the Auckland DHB achieved 12 per cent and Counties Manukau 13 per cent. …

And the proportion of elective surgery the DHB contracts to the private sector remained stable last year at about 12 per cent.

This could be a lesson that there is a big difference between spending and effective spending.  Tony Ryall is obviously managing the latter.

One of the things that many may not realise around Obama’s Healthcare Reform, is that it does not in fact create a public health system. To increase health insurance coverage, it has made it illegal not to have health insurance, with limited exceptions such as hardship or religious belief.

If a Republican President had tried to make private health insurance compulsory, I suspect the left would have decried the reform, instead of supported it. And i guess the right would have supported it, instead of opposed it.

13 states have filed lawsuits claiming it is unconstitutional to force people to take our private health insurance. I suspect this issue will get to the Supreme Court, and you do have to think there is a reasonable chance that may breach the Bill of Rights.

What I find ironic, is that Obama’s reforms have now made the US system almost the polar opposite of the Canadian system.

You see in Canada, it is illegal in some provinces to even have private health insurance. And federally there are laws that forbid hospitals from charging private rates (even if a private clinic).

So effectively in Canada it is illegal to have private health insurance, and now in the US it will effectively be illegal NOT to have private health insurance.

The Herald reports:

Parliament’s health committee is considering whether parents should be offered cash incentives to have their children immunised, or even have benefits withheld if they don’t without good reason.

Committee members were in Canberra last week looking at several issues including how Australia had dramatically improved its childhood immunisation rates and will report to Parliament on its trip.

Chairman and National MP Paul Hutchison said 91 per cent of Australian 2-year-olds were now fully immunised against little more than 50 per cent 10 years ago. In New Zealand the rate is about 75 to 80 per cent.

That is an impressive increase in Australia. The rate in NZ is highly variable. Probably close to 100% in some areas, and under 50% in others.

Australia’s success had been been achieved with a seven point plan, including some measures such as a childhood immunisation register which is already in place here.

However, Dr Hutchison said he was particularly impressed with the effectiveness of cash incentives for families and health professionals in increasing immunisation rates.

Parents of 18-month-olds who had received all required shots received a A$125 ($163) cash payment. Another payment was made to parents of fully immunised 4-year-olds.

Other measures included requirements at some schools and pre-schools for children to be fully immunised before they could be enrolled.

I instinctively don’t like the idea of paying parents to do something they should do anyway, but you know if it works, it would be worth it for the savings in health.

However what would be good is some research into what has most contributed to the lift in rates in Australia – is it the cash payments or is it the requirement in some schools to be immunised to enrol?

It is inevitable that a future Labour Government will include the Greens, as they no longer have Jim or Winston to rely on. So with that in mind, let us look at what the Greens say their health priorities are:

1. In retrospect I have to confess that our decision to fund 12 months’ treatment with Herceptin was sheer irrational populism, and today I’m announcing that we will never do it again. In the same spirit, our repeal of the healthy school food guidelines and cutting funding to Healthy Eating Healthy Action projects were entirely about ideology rather than health, so we’re reintroducing them because we are quite concerned about chronic illness.

So their number one health priority is to provide a shorter period of treatment to women with breast cancer. I can’t wait for No 2.

2. Rather than making the grand gesture of a massive programme to build new operating theatres and contracting out surgery to the private sector, Government has today announced a programme of regionally (rather than locally) planning the best and most efficient use of our existing theatres, specialists and resources.

And their number two health priority is to have fewer operating theatres. This just gets better and better. Vote Green and we promise less treatment for women with breast cancer and fewer operating theatres.

3. I think we’ve had enough of committees, reports and endless restructuring, so rather than commission yet more I am going to require DHBs to work together and help each other whenever this is in the interests of most New Zealanders.

Their third health priority is that they are going to send a memo out to DHBs telling them to work together better.  Such vision.

4. It is inadequate and unacceptable for us to set lower health targets for Maori and to continue to tolerate health inequalities. The performance measures I am setting for DHBs will focus on raising Maori health status to the same level other New Zealanders enjoy, and DHBs will perform to this standard (or they’re all fired!)

This one is so crazy, it has me laughing. The Greens are going to sack every District Health Board in New Zealand unless they can get Maori health status to the same level as non-Maori. Are they going to supply pixie dust to help them do the job?

It is an interesting insight into the mind of those on the hard left. They really believe that the reasons for the disparity between Maori and European has nothing to do with culture, genetics, environment, family and personal decisions – but is all the fault of the DHBs, who will be sacked if they can’t fix it.

5. In order to improve the position of those people with the poorest health, Government will be requiring all Government departments and crown entities to work together at a local level to identify people in need and to proactively offer services to improve their lives, and will be funding PHOs to take a lead role in this process.

So number five health priority is to send out a memo to Government Departments asking them to work better at helping people with poor health.

6. There is not enough money now to provide all of the health services that New Zealanders expect, and this will be worse in the future. Consequently Government is reorienting our health sector spending to focus resources in the areas proven to have the greatest impact on population health status, public health programmes and primary care, and as Minister I will also personally lead a national conversation with New Zealanders about how we best make decisions about how we should allocate limited resources in secondary and tertiary care.

And their final health priority is to have a conversation about umm health priorities, with an eye towards reducing secondary and tertiary care.

So in summary these are the Green’s six priorities for health:

1. Reduce the amount of treatment for women with breast cancer
2. Reduce the number of operating theatres
3. Send out a memo to DHBs saying work better together
4. Sack every DHB in New Zealand if they can not magically bring Maori health status up to the level of non-Maori
5. Send out a memo to Government Departments to say be nicer to people with poor health
6. Try and convince NZers to have less money spent on surgery and hospitals.

Oh I am looking forward to a future Labour/Green Government. It will be such fun.

The NZ Herald looks at the TVNZ decision to bump John Key for Robin Brooke:

It is reassuring, in its way, that the Prime Minister could not commandeer the airwaves on state television on Tuesday to tell the nation about income tax cuts and a rise in GST. It speaks of TVNZ independence and editorial freedoms that should be valued, however questionable the actual judgment of those exercising them.

The Herald also looks at the drug law reform paper:

Mr Power’s problem with the Law Commission recommendations seems to stem from from the Prime Minister’s declared war on methamphetamine and drugs. Any relaxation would be perceived as contrary to that. It could also be argued, as John Key did yesterday, that softening the law on the possession of drugs for personal use would send the wrong message to youngsters. …

Given such political reality, there was a strong whiff of naivety in the commission’s suggestions. There was also, however, a solid strain of reason and rationality.

The commission, for example, is right to note that “while the harms and costs associated with alcohol are understated and misunderstood, those associated with illegal drugs are often generalised and overblown”. There is also much to say that drug policy should focus on dealing with problematic drug-users, rather than the many people whose drug use poses no serious threat to their own well-being or others.

I agree. that the focus should be on those drug use creates problems, rather than those who do not.

The Dominion Post talks about PHOs:

On paper, the last government’s decision to establish primary health organisations had a lot going for it. Bringing together doctors, nurses, midwives and other health professionals under one roof was a way to improve access to services and reduce overall health costs by reducing the need for hospital admissions.

In practice, as invariably happens when a government opens its cheque book, the results have been mixed.

A study by Capital and Coast District Health Board last year showed avoidable hospital admissions in the district have increased since 2003, but have fallen among people enrolled with PHOs. PHOs are also credited with increasing immunisation rates in some parts of the country and making visits to doctors more affordable for people in poor areas, although the latter is more likely to be a consequence of increased subsidies than the way the sector is organised.

However, some PHOs barely exist except on paper (their purpose is to channel money from district health boards to individual clinics) and their creation has contributed to a rise in administration costs.

Not exactly a stunning success.

The Press talks about Environment Canterbury:

For the second year in a row Environment Canterbury (ECan) is heading towards an overall rate increase well in excess of inflation.

Last year it approved a rise of 6 per cent, including a 10.6 per cent general rate rise, but if that decision prompted disquiet in the region, the questioning of ECan could well be even stronger this year. …

With the local body elections looming later this year, ECan ratepayers will be closely watching over coming months to see which councillors are prepared to identify areas where savings could be found, especially in the regional council’s bureaucracy.

We should have candidates sign pledges that they will not increase rates beyond inflation without voter approval.

The ODT looks at the merger of the Otago and Southland District Health Boards:

The way is cleared for the merger between the Southland and Otago District Health Boards with the Southland board’s 7 to 3 vote in favour.

Because Health Minister Tony Ryall is likely to back the proposal, the only remaining major issue is the speed of approval and whether the Southern Board will be in place early enough for this year’s local body elections in October. …

I suspect it will be.

The Herald reports:

Primary health services are about to undergo their biggest shake-up in nearly a decade, shifting some hospital services into the community and creating new super-clinics.

The kinds of services the integrated family health centres might offer are expected to include minor skin surgery, referral to diagnostic imaging and consultations with hospital specialists. …

The Health Ministry has provisionally accepted nine bids from groups of PHOs and DHBs for devolution of some hospital services to primary care – they must remain free to patients – and the creation of integrated family health centres.

It all seems sensible, so I wonder why it hasn’t happened earlier.

Services provided by integrated family health centres could include:

* 24-hour accident and medical care.
* Laboratory collection, some on-site testing.
* Clinical psychology, counselling.
* Dental care.
* Midwifery clinics.
* Acute assessment and observation beds.
* Minor surgery.
* Consultations with specialists.
* Referral for magnetic resonance imaging.

It will be interesting to see one in operation.

John Armstrong writes:

It is not that long ago – only a matter of months – that the loss of 500 jobs in a crucial branch of the state sector would have been the major news story of the day. …

The same could not be said about this week’s announcement that the axe will fall on close to 500 positions in the Ministry of Health and across the country’s 21 district health boards over the next 18 months.

The media reaction was very ho-hum despite the layoffs actually being closer to 700 once 200 vacant positions in the Ministry of Health which will not be filled were included in the tally. …

Increasingly, the feeling is that the public has – to borrow from Helen Clark – moved on from the days when it could get outraged by the merest hint of slash-and-burn spending cuts or privatisation. The assumption was that National won last year’s election through John Key positioning his party more to the centre. It is clear now that a large portion of the electorate had already shifted to the right.

John is partly right here, but only partly. The public mood has shifted, but I would not call it a shift to the right. It is the same shift we have seen in the UK, where most of the public now support spending cuts.

It is not a change in political views, but a reaction to the recession. Part of it is a feeling of shared belt-tightening. If businesses and households can tighten their belts, so can the Government. And it is partly that people do understand huge deficits and massive borrowing is not sustainable.

The other aspect I would point out is that it is hard to call what Ryall is doing as slash and burn spending cuts. He has promised that Vote Health will not decrease, but the gains from the bureaucracy reduction will be transferred into frontline services. This changes things considerably.

Well almost the entire health sector seem to be united behind the changes announced by Tony Ryall. This degree of unanimity is very rare. In fact I think the last time it happened was in the early 90s when the Young Nats proposed selling off all 23 CHEs to the private sector (on the basis of there being a funder/provider split, and ownership of providers did not matter), and we got condemned by every health group and political party there was – including National’s own Minister and Under-Secretary

Getting widespread support in favour, rather than against, what you are doing is harder but here is reaction yesterday:

NZMA:

The New Zealand Medical Association (NZMA) today welcomed the announcement by the Government of substantial changes to the health system.

“It makes great sense to rationalise the backroom services of the District Health Boards (DHBs) and to provide much greater coordination of national services and we support the decision to place the National Health Board within the Ministry of Health,” said NZMA Chair Dr Peter Foley.

NZNO:

The New Zealand Nurses Organisation (NZNO) supports announcements made today by the Minister of Health, Hon Tony Ryall, which will see greater collaboration in health across New Zealand’s 21 District Health Boards (DHBs).

“We are pleased that the Government and the Minister have taken heed of the submissions made in response to the Ministerial Review Group report ‘Meeting the Challenge’. We welcome any additional resources to workers at the front line of the health service,” said NZNO President Nano Tunnicliff.

“The changes signalled are a sensible continuation towards a more nationally integrated health service,” Tunnicliff said.

ASMS:

“We are chuffed that the government has listened to advice from us and others on the health proposed by the Ministerial Review Group (Horn Report),” said Mr Ian Powell, Executive Director of the Association of Salaried Medical Specialists, today.

“The Horn Report recommended creating a new bureaucracy, the National Health Board, as a separate, less accountable crown entity, in addition to the Ministry of Health. This would have involved major restructuring, and risked increasing bureaucratic wastage and generating paralysis in decision-making. We supported the functions proposed for the National Health Board but not the recommended structure.”

“We have worked hard lobbying government not to go down this path. Instead we recommended that the functions be allocated to a specific enhanced unit within the Ministry of Health. This is exactly what Health Minister has announced today and we are delighted. It is a relatively novel experience of a government listening to us in such a specific way.

And even the Health Cuts Hurt lobby group:

“Health Cuts Hurt supports the principles behind the Government’s decisions about the public health system announced today but is concerned that the devil is in the so far undelivered detail,”

“How can you oppose more consolidation of the administrative functions like purchasing in bulk and more regional cooperation in service delivery along with returning savings from these things into more operations or hospital beds,” said Heather Carter.

Oh I am sure Labour can, if they try hard enough

HFANZ:

Efficiency gains expected as a result of changes to the public health system announced by the Government today have been welcomed by the Health Funds Association (HFANZ).

Tony Ryall really is doing well with what is traditionally a very dangerous portfolio. If only, the same could be said across the entire Government!

Tony Ryall has announced:

“Cabinet has agreed to a number of proposals from the Ministerial Review Group’s report ‘Meeting the Challenge’ that will greatly improve national and regional cooperation and reduce duplication of back office functions, ” the Minister said.

As a package, the changes will move up to an estimated $700 million in savings over five years to frontline services. That would buy about 16,000 heart bypass operations or build two large city hospitals.  The changes are also expected to reduce the health system bureaucracy by up to 500 administration jobs. These would be managed as much as possible through attrition and voluntary redundancy. …

The major changes include setting up a new National Health Board (NHB) within the Ministry of Health. The NHB will focus on supervising the $9.7 billion of public health funding the 21 DHBs spend on hospitals and primary health care.

The new NHB will manage national planning and funding of all IT, workforce planning and capital investment. It will also take national responsibility for vulnerable health services such as paediatric oncology.

Work will also start on consolidating the 21 DHBs’ back office administrative functions such as payroll and bill payments.

“Officials estimate a one-off cost of between $5 and $10 million to set up the changes and that will be met within the Vote Health budget. Up to an estimated $700 million is expected to be saved in the first five years from coordinating procurement and logistics. All savings will be reinvested back into frontline health services.”

I don’t think anyone can object to the intention of these changes. If they save even a fraction of what the official cite, that will be a good thing freeing up money for frontline services.

The challenge for the Government is to have them go smoothly. INCIS is a prime example of good intentions going astray.

But I’m pleased the Government is prepared to take the risk, in order to make improvements. The status quo is not good enough.

MacDoctor nails it here:

If you were wondering why Labour spent so much extra money on Health without actually improving the health of New Zealanders, nor their access to services, puzzle no longer. Ruth Dyson reveals all. She is complaining that some of the health promotions that were dear to Labour’s heart have been cut or seriously curtained. Things like cancer “control”, heart promotions and the diabetes “get checked” programme. …

No, Ruth, these are NOT frontline services. They never were and they never will be. These are all Labour’s attempts at preventative health promotion and, as such, provide no health service at all. This is not to say that preventative health is necessarily useless, just that they are not frontline services. They are not delivering medicine, they are delivering social change. At least, they might be delivering this.

That is a great line – they are not delivering medicine, they are delivering social change.

That does not mean all public health activies are not worthwhile, but they are not the same thing as actually giving someone an operation, a prescription etc.

The biggest problem with all of these preventative health schemes is that no one appears to have bothered to examine whether they are making any difference. Labour’s attempt to monitor results of these campaigns (now removed from the health reporting list by National) were so wishy-washy and soft, that it was impossible to tell from the data whether they were successful. That does not seem like a good use of taxpayer dollars to me.

Take the diabetes programme “get checked”, for example. This programme, unlike most, actually has links to hard data like blood results, blood pressure readings and hospital admission rates for diabetes and diabetic complications. All the hard evidence shows that the programme has made virtually no difference to the quality of diabetic control.

Huge amounts have been spent on programmes that *might* improve health outcomes. But what data there is, is patchy.

Diabetics who normally don’t attend their regular check-ups don’t abscond because they can’t afford it, they don’t come in because they can’t be bothered. Diabetes is one of those diseases that kill you slowly, like high blood pressure (only worse). People don’t like to see the doctor unless they are sick. So they don’t. All that “get checked” does is make it cheaper for the people who would have regularly attended their doctors for diabetic monitoring. It is a subsidy for diabetics. Nothing more, nothing less.

More middle class welfare.

There is nothing wrong with this. It is just not something you want to fund at the expense of real frontline services like outpatient visits and elective surgery.

Which is what Tony Ryall is sensibly targeting.

Labour’s singular failure in health is their constant focus on what would be nice at the expense of focussing on what is truly needed.

Dead on target here.

Nobody is saying that heart prevention programmes are invariably a waste of time. We may demonstrate that they may be very useful indeed at reducing long-term heart disease. But it is not right that a dozen people should die because they can’t get heart surgery in time in order to fund a social intervention. Particularly one that does not have demonstrable benefits.

This is how Labour managed to double health spending but almost make no impact on waiting lists etc.

Tony Ryall announced yesterday $104 million over four years for additional maternity funding:

• Longer stays for new mothers in birthing facilities
• An optional meeting each trimester for at risk mothers, attended by the pregnant woman, their GP, and their lead maternity carer (usually a midwife)
• Obstetric training or refreshers for GPs wishing to return to maternity care
• Fully funding the Plunketline 24 hour telephone advice service

I think the second point may be the most important. The changes made in the late 1980s by then Health Minister Helen Clark have been a disaster for many parents. GPs have abandoned maternity services, and doctors and midwives have often been silos – not talking to each other.

And far far too many babies have died needlessly, because of a lack of competence amongst some (not all) midwives. A refusal to call in a specialist has proven fatal too often.

So the three monthly meetings between mother, GP and leader carer is a commendable initiative.

The NZ Herald editorial favours the new health targets:

Targets can be the bane of any organisation. Unless they are well defined and readily measurable they are worse than useless, create more work than necessary and waste time and money that could be used for something more useful. The Minister of Health, Tony Ryall, has found some classics among the previous Government’s targets for district health boards (DHBs), which he has culled from 10 to six.

Worse than that:

As he put it, “We have inherited a system overburdened with 13 health priorities; 61 objectives, with an additional subset of 13 health objectives; a set of 10 health targets measured through 18 indicators; 25 other indicators of DHB performance; not to mention four hospital benchmark indicators assessed through 15 measures; and an outcomes framework with nine outcomes measured against 39 headline indicators”.

And think of all the administrators needed both at DHB level, but also at the MOH to measure and report on all these.

When Labour scrapped the previous National Government’s business model for hospitals and related services, replacing Crown health enterprises with district health boards, it made much of the democratic element of elected boards. But in fact the boards were set up as branch offices of the Health Ministry, which decided most of what they would do.

Having elected members on DHBs, actually dilutes accountability as it allows the Minister to blame the local DHB and vice-versa.

This Government is content to keep Labour’s administrative structure and the best it can do is try to simplify its procedures. Impractical, largely symbolic declarations on nutrition, obesity and physical activity have gone. As Mr Ryall said, how could a district health board be held responsible for increasing the number of people who ate the recommended daily portions of fruit and vegetables?

The six goals he has set look sharper: shorter stays in emergency departments (95 per cent of patients to be admitted, discharged or transferred within six hours), faster elective surgery (an increase of 4000 a year), shorter waits for cancer treatment (radiation within six weeks by August next year, and four weeks by December).

Those three are treatment targets, the rest are preventive: immunisation for 85 per cent of 2-year-olds by July next year, rising to 95 per cent two years later; help for hospitalised smokers to stop; more people to be assessed for risk of heart disease and more free checks for people with diabetes.

Inevitably, there will be complaints that worthy causes have been ignored. Already the Obesity Action Coalition asks where responsibility for nutrition, physical activity and obesity lies if not with health boards. Well, many could answer that one. It lies with the individual.

You can’t trust individuals – once you start doing that, society will crumble.

The ODT reports that Tony Ryall has set just six targets for DHBs (I presume on top of don’t run out of money). They are:

1. cut emergency department waiting times so 95% treated within six hours
2. deliver faster treatment for cancer patients – all those needing radiation treatment to get it within six weeks by July 2010 and within four weeks by Dec 2010
3. carry out more elective surgery – an extra 4,000 operations per year
4. more immunisations – 85% immunised by July 2010, 90% July 2011 and 95% July 2012
5. better help fro smokers to quit – 95% of smokers in hospital to be given advice and help to quit
6. better diabetes services

What were the targets from the previous Government:

1. 13 health priorities
2. 61 objectives
3. additional subset of 13 health objectives
4. 10 health targets measured through 18 indicators
5. 25 other indicators of DHB performance
6. 4 hospital benchmark indicators assessed through 15 measures
7. an outcomes framework with 9 outcomes, measured against 39 headline indicators

Sounds like doctors may have more time to see patients and be spending less time reporting on priorities, objectives, indicators and outcomes. Also sounds like we may have a few less administrators.

I saw in the Herald that a Tim Dare has responded to the excellent op ed by Dr Shaun Holt on the bureaucratic PC ethics approval system for the most basic of health experiments (the example was honey on a rash).

Now when Dr Holt did his original op ed I noted he provided an actual example of how the system was nonsense, and that he spoke from first hand knowledge, being a Doctor.

So before I even read Tim Dare’s response, I crolled down to the end to find out whether he was someone with a vested interest in defending the status quo. And indeed:

Dr Tim Dare is head of the department of philosophy at the University of Auckland and chairman of the Health Research Council ethics committee.

Interesting. Dr Dare is chairman of the HRC ethics committee (which makes him the ultimate vested interest) but he is also (to quote Rob Muldoon) one of those doctors who makes you sick, not well

But what does he say:

Dr Holt is moved in part by his experience as a former ethics committee member and researcher. He recently sought approval for a study looking at whether honey helped treat a common childhood skin condition.

“Only 15 children were required,” he reports, “and all the caregivers had to do was to apply the honey, cover with a dressing and see if it seemed to help.”

The ethics committee refused permission, he says, raising more than 40 objections. He gives as an example of its obstructive approach a requirement for Maori consultation.

This is misleading. I was a member and chair of New Zealand’s busiest health research ethics committee for seven years. Some very difficult applications, such as those requiring the development of new policy, took a long time. But the vast majority were dealt with at the meeting following their receipt (within two or three weeks), as required by national guidelines. Even allowing time for letters following that meeting, few were still open six to eight weeks after receipt.

He says this is misleading, but nowhere does he dispute that Dr Holt was refused permission and had over 40 objections to overcome to what appears to be the most simple of experiments.

And rather than quote actual statistics on turn-around, we only get told ” the vast majority” and “few”. I prefer hard numbers. But the issue is not just about time to make a decision, but the hurdles that applicants have to jump through prior to application.

Delays beyond that were often because researchers took time responding to committee requests for clarification or amendment.

So it is their fault. Again no statistics on this.

Dr Dare turns to Dr Holt’s proposal and comments:

Dr Holt’s account of the treatment of his own proposal is also less than complete. Ethics committee minutes are publicly available. The minutes for Dr Holt’s study before the Auckland committee (to see them, run NTX/08/09/085 through Google) indicate that the committee deferred a decision on Dr Holt’s honey project because they were concerned about its validity.

They seem concerned the study did not have enough participants and that parents were required to change dressings and wash the affected area during the study without an indication how Dr Holt would know whether it was the honey or the washing that made the difference. There is mention of Maori consultation, but it is not given as the primary reason for deferral.

These are very ordinary concerns about research validity: one of the legitimate roles of an ethics committee is to ensure that health therapies cannot claim to have been shown effective unless the research is rigorous and sound.

Note that the committee did not decline approval: they deferred a decision. Dr Holt chose to not clarify or amend his study.

It was good of Dr Dare to provide the Google reference as it does provide the minutes of the meeting. But I think the minutes prove Dr Holt’s point. Look at the changes that were demanded for such a simple study:

• Study, as it stands, is a pilot and this needs to be stated in the title, and then reflected in the design, the research question(s) and the PIS and consent form. Alternatively, the researcher may choose to power the study, after consulting a statistician
• Guidelines NAFG to be consulted.
• Part 1: Provide positions/qualifications/organisations of co-investigators
• A3.1: Insert information regarding washing the MC lesion every 2 days (same as PIS).
• A1.2: Explain what type of honey will be used and the justification for using this.
• A3: Study Design: It is planned to dress 1 MC with honey, cover it then, for the next four weeks, wash it every 2 days wash it, dress it with honey and cover it while the other MC is left untouched. Clarify how the researcher will determine which of these interventions is causing any effect seen.
• A3: Randomize over two chosen sites, and include an osmolarity control.
• A3: Explain how participant compliance with study design will be monitored between visits
• A4.1: Explain how the 15 child participants will be assigned in respect of each locality
• B10: Grounds for exclusion to be ‘factual’ not left to doctor.
• B11: Provide worksheet. What information is being collected and why?
• B12: Explain why a dressing known to cause allergic reactions will be used, rather than a non-adhesive dressing, and explain how the cause of any adverse reaction will be ascertained.
• B12: If removed from the study what treatment will be offered to the child?
• B16: Clarify ‘safety reasons’.
• D5/6/7: Data to be kept until age of majority plus 10 years (Health Act – Children)
• E: Researcher to explain how interpreters are accessed, if used
• Section F: Consultation needed from Tauranga Maori Health Providers. Honey is food – are there cultural implications?
• Locality Assessment Cannot be signed by PI. To be redone.
• Pt 4 Declaration: 2: Cannot be signed by PI. To be redone.
• B11: Provide worksheet?
• Provide an information sheet/consent form for children under 15.
• A8.1: Provide itemised budget that justifies the $900 payment to doctors. Without such detail we are unable to assess whether the payment to doctors might act as inappropriate inducement to recruit and retain.
• D4: The committee is concerned that having the initial approach made by the GP increases the potential for conflict of interest and coercion of the participant, given the payment per participant that is proposed.

Hell I would have given up at this point also.